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EM@3AM: Hyperthermia

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A 34-year-old male is brought via EMS after collapsing during an outdoor adventure race. EMS reports the patient was conscious but altered, with slurred speech and confusion. Point of care glucose in the field was 102 mg/dL. Vital signs include BP 80/40 mm Hg, HR 154 bpm, T 41C rectal, RR 28 breaths per minute, saturation 94% on room air.  The patient is agitated, not oriented, and becoming combative with ED staff.  A 12-lead EKG shows sinus tachycardia but is otherwise normal.  As you attempt to examine the patient, he has a generalized, tonic-clonic seizure. What is your diagnosis, and what are your next steps in evaluation and management?

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EM@3AM: Oculomotor Nerve Palsy

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A 50-year-old female with no past medical history presents to the ED with a diffuse, constant headache onset a few weeks. The patient describes droopiness of the left eye and double vision associated with specific directional movements of the eye. On exam, you note ptosis of the left eye with findings as indicated in the photograph below (inability to adduct, ability to abduct). The left pupil is dilated at 5mm and minimally reactive to light; the right pupil is 3mm and reactive. The remaining cranial nerve testing and components of the neurological exam are normal.

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EM@3AM: Liver Transplant Complications

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A 32-year-old female with a history of hypertension and autoimmune hepatitis status post liver transplant 6 weeks prior on tacrolimus and mycophenolate presents to the ED with abdominal discomfort. For the past two days, she describes worsening pain and intermittent vomiting. She came today because her sister is a nurse who noticed her eyes were yellow. She denies fever or a new rash. She has been taking her medications as prescribed. Vital signs: HR 118, BP 103/68, RR 20, T 99.8. On exam the patient is tachycardic with RUQ pain to palpation and scleral icterus. LFTs are in the thousands.

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EM@3AM: Basilar Artery Occlusion

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A 68-year-old male with a past medical history of hypertension, diabetes mellitus, and CAD with a drug eluting stent placed 2 months ago presents with dizziness and vomiting that began 3 hours ago. He has been having “issues with [his] eyes” today and “not feeling quite right.”  Vital signs include BP 165/83, HR 81, RR 18, SpO2 96%. On exam, you notice he has dysarthric speech, limb ataxia, and vertical gaze palsy, which he reports is new. You perform a NIHSS which scores a 3 for mild dysarthria and ataxia in two limbs.

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EM@3AM: Crush Injury

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A 17-year-old girl, in moderate distress, is brought in by EMS after a motor vehicle collision. EMS reports that she was “pinned” underneath the dashboard, and it took several hours to extricate her. Triage vital signs significant for BP 103/69, HR 99, SpO2 99% on 2 L NC, RR 25, Temp 98.6. She has normal mental status but is in distress with severe pain in her legs. On exam she has erythema, ecchymosis, and gross deformities to bilateral lower extremities but intact distal sensation and palpable pulses. She refuses to move her legs secondary to pain. Laboratory testing reveals elevated potassium and CK. What is the diagnosis?

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EM@3AM: Brugada Syndrome

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A 36-year-old female presents to the ED after experiencing an episode of sudden syncope. The patient has no significant past medical history, and reports that she was walking to the end of her driveway to retrieve her mail when she suddenly collapsed to the ground. She recalls waking up on her driveway with concerned neighbors gathered around her. The patient states that this has never happened before. On arrival, she is stable and well-appearing. Exam is normal. ECG demonstrates coved ST segment elevation >2mm in V1-V3 followed by a negative T wave. What is the diagnosis?

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EM@3AM: Oropharyngeal Candidiasis

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A 32-year-old male with HIV presents to the ED for loss of taste. He noticed white plaques on his tongue. Although painless, the plaque is associated with a cotton sensation and a dull sense of taste. The patient reports being compliant with his medications and denies other symptoms. His tongue is covered in white curd-like plaques that are easily removed with scraping, leaving behind an erythematous base. The posterior oropharynx is without abnormality. What is the diagnosis?

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